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By Martin Kulldorff and Jay Bhattacharya
The idea that everyone must be vaccinated against COVID-19 is as misguided as the anti-vax idea that no one should. The former is more dangerous for public health. The COVID-19 vaccines have been one of the few bright spots during this pandemic. While anyone can get infected, the old have a thousand-fold higher mortality risk than the young.
By vaccinating older people, the country has saved thousands of lives.
There is intense pressure on young adults and children to be vaccinated. Universities such as Colombia, Cornell, Harvard and Stanford require all students to get the shot as a condition of attending college normally. Young people looking for work are discriminated against if they are not vaccinated. It makes public health sense to require some vaccinations in some settings. However, in the case of COVID vaccines for young people, such mandates harm public health.
First, all medical interventions should pass the test of providing more benefits than risks. For the COVID vaccine, this is decidedly true for older populations but it is not yet clear for younger people. While we know that COVID vaccines have common but mild adverse reactions, we will not know enough about rare but serious adverse reactions until a few years after vaccine approval.
For older people, this does not cause a dilemma. Even if there is a small risk of a serious adverse reaction, that is still better than the much higher risk of dying from COVID. Hence, we should do everything we can to encourage vaccination for older people, including less affluent people whom our health care system often has difficulty reaching.
For younger adults and children, it is a different story, as their mortality risk is extremely low. Even a slight risk of a serious vaccine adverse reaction could tip the benefit-risk calculation, making the vaccine more harmful than beneficial. We have already observed rare problems with blood clots (J&J vaccine) and myocarditis (inflammation of the heart muscle, Pfizer and Moderna) in younger people, and additional equally serious issues might still be found.
Under such uncertainty, vaccine mandates are unethical. University presidents or business leaders should not mandate a medical intervention that could have dire consequences for the health of even a few of the people in their charge.
Second, recovered COVID patients have strong long–lasting protection against severe disease if reinfected, and evidence about protective immunity after natural infection is at least as good as from the vaccines. Hence, it makes no sense to require vaccines for recovered patients. For them, it simply adds a risk, however small, without any benefit.
During the pandemic, the professional laptop class protected themselves by working from home while exposing the working class that brought them food and other goods. It is now the height of hypocrisy to recognize immunity from vaccinations but not immunity from those exposed while serving the laptop class.
Third, the pandemic is global. In most countries, older high-risk people have not yet been vaccinated. With a global vaccine shortage, every dose given to a low-risk young adult in the United States means one fewer dose available for high-risk older people in Brazil, Congo, India or Mexico. When American universities and companies mandate vaccinations, they are not only failing the young in this country, they are also indirectly responsible for the death of older people in the developing world.
Fourth, public health relies on trust to be effective. But the public will not trust public health advice unless public health officials reciprocate by trusting in the public. Vaccine mandates go against this basic principle of public health. They will backfire by increasing vaccine hesitancy, not just for the COVID vaccine but also for other essential vaccines, including polio, measles, human papillomavirus and meningitis, to name a few. We have spent decades building trust in vaccines by informing people about their benefits and risks. This effort has been very successful despite a small vocal minority of anti-vaxxers. To push for vaccine mandates now threatens to reverse this progress. We cannot let that happen or else harm public health.
Universities used to be bastions of enlightenment. Now many of them ignore basic benefit-risk analyses, a staple of the toolbox of scientists; they deny immunity from natural infection; they abandon the global international perspective for narrow nationalism; and they replace trust with coercion and authoritarianism. Mandating the COVID-19 vaccine thus threatens not only public health but also the future of science.
Martin Kulldorff, PhD, is a biostatistician, epidemiologist and professor of medicine at Harvard Medical School. He does research on disease surveillance methods for post-market drug and vaccine safety surveillance and for the early detection and monitoring of infectious disease outbreaks. Jay Bhattacharya, MD, PhD is a professor of medicine at Stanford University and a research associate at the National Bureau of Economic Research.